MEDICARE: MRS. ELLEN MARGO KLEIN-SOUTH M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	SS0000535	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z127B	OTHER	FL	BLUE CROSS/ BLUE SHIELD INSURANCE

General Provider Information

NPI Number	:	1679872394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELLEN MARGO KLEIN-SOUTH M.S.

Provider Business Mailing Address
First Line	:	3881 NE SUGARHILL AVE
Second Line	:
City	:	JENSEN BEACH
State	:	FL
Zip	:	34957-3731
Country	:	US
Telephone Number	:	772-334-4035
Fax Number	:	772-334-4036

Provider Business Practice Location Address
First Line	:	3881 NE SUGARHILL AVE
Second Line	:
City	:	JENSEN BEACH
State	:	FL
Zip	:	34957-3731
Country	:	US
Telephone Number	:	772-334-4035
Fax Number	:	772-334-4036

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2011
Last Update Date	:	03/21/2011

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